LSVT LOUD Supported by Empowering People Parkinson’s Live

Copyright LSVT Global, Inc. 2020 1

LSVT LOUD® Speech TreatmentEmpowering People with Parkinson’s disease

to Live LOUDER and BETTER lives

Innovation in Science. Integrity in Practice.

Supported by• National Institutes of Health ‐ National Institute Deafness and Communication

Disorders (NIH‐NIDCD)• Office of Education‐National Institute for Disability and Rehabilitation Research (OE‐

NIDRR)• Coleman Institute • Hearst Foundation• Axe‐Houghton Foundation• Family of Lee Silverman• Davis Phinney Foundation • Parkinson Alliance• Supported by NIH grants: R01DC01150, R21 RFA‐NS‐02‐006 R21DC006078, R21NS04371

R43DC010956, R43DC010498, R43DC00741

DisclosuresI do not have any financial relationship with LSVT Global, Inc. nor am I representative. This informational lecture was provided by LSVT Global for use by LSVT LOUD Certified Clinicians for the purposes of informing the public and/or other healthcare professionals about LSVT LOUD. Viewing the information and videos contained in this lecture do not constitute LSVT LOUD treatment. Patients interested in receiving LSVT LOUD should consult with their doctor or LSVT LOUD speech therapist. Healthcare professionals viewing this information are not permitted to use the exercises described in the lecture and videos without becoming LSVT LOUD Certified themselves.

What you will learn!

Impact of neuroplasticity in rehabilitation for people with PD

Background and development of LSVT LOUD

LSVT LOUD key concepts and foundational research

Summary of the LSVT LOUD protocol

Introduction to LSVT BIG and technology for LSVT LOUD

How to get started with LSVT LOUD and

LSVT BIG

Parkinson Disease (PD)A Global Pandemic?

Up to 8 million people worldwide are living with PD.

Dorsey ER, Bloem BR (2018) The Parkinson Pandemic—A Call to Action. JAMA Neurol. 2018;75(1):9-10. doi:10.1001/jamaneurol.2017.3299

Number of people with PD is expected to DOUBLE by 2040

Our Mission

To empower people with Parkinson’s to

restore and maintain their highest levels

of functional communication, mobility and

independence in daily life through

scientifically supported therapy programs:

• LSVT LOUD® Speech Therapy

• LSVT BIG® Physical & Occupational Therapy

It is a “Stunning Time” to be in rehabilitation today

• Basic science evidence for the value of exercisein PD has been established (classically drugs, surgery, today…)

• Identified key principles of exercise that drive activity‐dependent neural plasticity

• Demonstrated that exercise can improve brain functioning (neural plasticity) and may slow symptom progression

• Exercise is Medicine!

Kliem & Jones, 2008; Ludlow et al, 2008

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Rehabilitation (ST, PT, OT) is becoming a routine part of management in PD

To provide symptomatic relief; improve function

Pharmacological(L‐dopa)

Speech, PhysicalOccupational Tx

(Empower)

Neurosurgical(DBS‐STN)

Kleim & Jones, 2008; Kleim et al., 2003; Zigmond et al, 2009

Video: Before and After LSVT LOUD• 59 year‐old female, 2.5 years since diagnosis

• Changes noted in her voice and speech

• She is ON medications in the before and after videos and she had no changes in medication

• Intensive one‐month speech therapy program

Over 89% of individuals with Parkinson disease worldwide suffer from voice and speech disorders.

• Reduced vocal loudness, monoloudness• Hoarseness, harsh or breathy voice quality• Monotone voice • Imprecise articulation

Aronson, 1990; Harel et al, 2004; Little, et al, 2008; Logemann et al., 1978; Ruiz et al., 2011; Sapir et al., 2001; Skodda, et al, 2009; Stewart et al, 1995

Speech disorders in Parkinson disease

• Even people who are clinically asymptomatic for speech deficits report feelings of embarrassment, social stigma and social isolation due to speech concerns (Miller et al., 2006a, b)

Does this matter?

• Consequences include being excluded from conversations, a loss of dignity and feelings of misery for many (Miller et al.,

2006a, b)

Impact of speech changes in PD

“If I have no voice, I have no life.” ‐Natalie, individual with PD

Classic Medical Treatments Alone do not Consistently or Significantly Improve Speech in PD

Pharmacological Treatment: “…no evidence of systematic improvement in dysarthria owing to dopamine replacement therapy.” e.g., Pinto et al, 2004

Surgical Treatment: Neurosurgical interventions do not consistently or effectively improve speech in PD e.g., Freed et al., 1992; Goberman, 2005; Pinto et al., 2004; Rousseaux et al., 2000; Tripoliti et al., 2008; Astromet et al., 2010

Voice and Speech Disorders in PD have been Historically Unresponsive to Speech Treatment

Despite efforts to improve voice and speech in PD (e.g., Sarno, 1968; Allan, 1970; Greene, 1980; Weiner and Lang, 1980; Robertson and Thompson, 1984 ; Johnson and Pring, 1990).

1987 no effective voice and speech treatments for PD

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“If only we can hear andunderstand her”Family of Mrs. Lee Silverman 1987

30+ year LSVT LOUD journey from invention to scale‐up

1987‐89: Initial invention; Pilot data Lee Silverman Center

1989‐91: Treatment development OE‐NIDRR

1991‐94: Treatment follow‐up OE‐NIDRR

1990‐95: Treatment Efficacy NIH R01 RCT

1995‐00: Underlying Mechanism NIH R01 RCT

2002‐07: Distributed effects NIH R01

2007‐12: Target/mode NIH R01 RCT

2001‐02: LSVT Companion Coleman Institute

2002‐04: LSVT Companion NIH & MJ FOX Foundation NIH R21

2002‐04: LSVT Virtual Therapist Coleman Institute

2004‐06: LSVT Virtual Therapist NIH R21

2004: LSVT Down Syndrome Coleman Institute

2006: Technology Enhanced Clinician Training NIH SBIR

2009: Telehealth Delivery of Software Enhanced LSVT NIH SBIR

2010: Independent Delivery of Software Enhanced LSVT NIH SBIR

1993‐present: Global LSVT LOUD Training & Certification Courses

Phase I, II

Invention

Phase III

Research

Phase IV, V

Clin

ical Im

plementation

TARGET: Amplitude ‐ Vocal loudness

MODE: Intensive and High Effort

CALIBRATION: Generalization

LSVT LOUD Key Concepts

Ramig, Bonitati, et al., 1991; Ramig, 1992; Dromey, Ramig, Johnson, 1994; Sapir et al., 2003; 2007; Fox et al., 2002; Fox et al., 2006

Incorporates principles of neuroplasticityAdministered in an intensive manner to

challenge the impaired system

SOFT

LOUD

Drive amplitude to override bradykinesia/hypokinesia

Loss of motor energyMovements underscaled

Berardelli et al, 1986; Hallett, 2011

Healthy Vocal Loudness

Mechanism of treatment related change: adductionIntensity across sessions:

Treatment delivered 4 consecutive days a week for 4 weeks. One hour, individual treatment sessions

Daily homework practice(all 30 days of the month)

Daily carryover exercises (all 30 days of the month)

Life‐long habit of continuous practice

Intensity within sessions: High effort

Amplitude, Repetitions, Force/resistance, Accuracy, Fatigue

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LSVT LOUD Calibration Addresses Barriers to Generalization

People with PD have soft speech, but they think it is within normal limits (world needs a hearing aide)

Speech that is within normal limits (normal loudness) is perceived by the individual as too LOUD

“I feel like I’m shouting.”

Fox et al., 2002; Sapir et al., 2011

What is the research on LSVT LOUD?

Evidence for LSVT LOUD3 Randomized Controlled Trials

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PRE POST FU

Change in dB SPL During Reading (30 cm)

LSVT RCT 3 ARTIC RCT 3 UNTX RCT 3

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PRE POST FU

Change in dB SPL During Reading (30cm)

LSVT RCT 2 UNTX RCT 2

Change in dB SPL During Reading (50cm)

1st RCT; n=45LSVT: Voice/respiratory targetRESP: Respiratory targetPre, Post, 6 mos, 12 mos, 24 mos

Ramig et al., 1995; 1996, 2001a

2nd RCT; n=30LSVT: Voice/respiratory targetUnTx: No treatmentPre, Post, 6 mos

Ramig et al., 2001b

3rd RCT; n=64LSVT: Voice/respiratory targetARTIC: Articulatory target UnTx: No Treatment

Ramig et al., 2018

Study Designs• Matched dosage• Matched intensity• Matched homework• Matched therapists’

enthusiasm• Repeated measures

for reliability• Uncued tasks• Data collected by

someone other than therapist

LSVT LOUD Patient Reported Outcomes

Ramig, Halpern, Spielman, Fox, & Freeman, 2018

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Spielman, et al., 2003Dumer et al., 2014

Facial expression

El-Sharkawi, et al, 2002: Miles et al., 2017

Swallowing

Smith, et al., 1995Adduction

Ramig & Dromey, 1996Aerodynamics

Baker, 1998; Luschei, 1999 Electromyography

(EMG)

Liotti, et al., 2003Narayana, et al., 2010Baumann et al., 2018

Neural ImagingDromey, 1995; Cannito et al., 2012

Articulation/Intelligibility

Sapir, et al., 2007; 2010Articulatory acoustics

Smith, A., 2001Speech Motor Stability

Taskoff, 2001Perceptual

Beyond Efficacy – numerous studies (over 30) examining distributed effects, neural correlates, mechanism of change

Ramig et al., 1995; 1996; 2001Intonation (STSD)

Baumgartner, et al., 2001Voice Quality

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1ml 3ml 5ml 10ml cup paste cookie

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Before LSVT

After LSVT

Swallowing before and after LSVT LOUD Approximate oral residue percentage (ORES) *=p<0.05

El‐Sharkawi et al., 2002

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• Subjects• 10 PD

• Paragraph reading

• Conventional subtraction analysis (task minus rest) plus correlational analysis with post‐LSVT changes in SPL

• Right brain (DLPFC, speech motor, premotor, multi modal parietal and auditory cortex)

• Optimizing speech network cortically

1 Bilateral SMA, 2 Right dorsal premotor cortices; 3 Left primary motor cortex (M1‐mouth);4 Right primary motor cortex (M1‐mouth); 5‐Right parietal cortex; 6‐Right dorsolateral prefrontal cortex, and 7‐Right superior temporal cortex

• To you

• To your MD

• Your family and friends

• Your speech clinician

• How does this research inform your LSVT LOUD Treatment?

Why does this research matter?“Knowledge is Power!”

Why does this research matter?

1. Provides therapists/patients with assurance they are providing/receiving a treatment that works, based upon strong research evidence to support its efficacy

2. Gives therapists/patients confidence in providing/receiving an intensive treatment which has sufficient repetition of practice and which includes sensory calibration, resulting in lasting changes as demonstrated clinically and in published research

3. Shows through multiple Randomized Controlled Trials (RCT) (3 for LSVT LOUD; 2 for LSVT BIG) the cause and effect relationship between the treatment delivered and the outcomes measured. The RCTs controlled for factors that influence treatment outcomes, such as attention, dosage, bias, etc.

“Knowledge is Power!”Why does this research matter?

4. Dispels concern of research bias when similar improvements post

LSVT LOUD and LSVT BIG have been published from multiple

laboratories and countries providing external validity of research

results.

5. Allows people with PD, family members, and physicians to advocate

for service providers that prioritize and offer evidence‐based therapy

treatments.

6. Protects physical, financial and emotional resources by participating

in treatments with efficacy versus potentially ineffective treatments.

“Knowledge is Power!”

LSVT LOUD Treatment SessionDaily Exercises

1. Maximum Duration of Sustained Vowel Phonation (Long Ahs) – 15+ reps

2. Maximum Fundamental Frequency Range (High/Low Ahs) – 15 reps each

3. Maximum Functional Speech Loudness (Functional Phrases) – 5 reps of 10 phrases

Hierarchy Exercises

Structured, personalized reading and spontaneous speaking – 25 min

Build complexity across 4 weeks of treatment

Week 1 – words, phrases

Week 2 – sentences

Week 3 – reading

Week 4 ‐ conversation

Homework

Includes all daily exercises and hierarchy exercises. Assigned all 30 days

Carryover Exercises

Use loud voice in real life outside of the treatment room. Assigned all 30 days

Shorter, simple

Longer, complex

LSVT LOUD Goal!

Treatment Goal: louder voice in conversationTreatment Exercise: “long ah”, “high/low ah”

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If you don’t feel like you are talking “too loud”

you are not talking loud enough!!

LearningCALIBRATION

LSVT LOUD® LSVTBIG ®

Ebersbach et al, 2010; Farley & Koshland, 2005; Fox, et al., 2012

Video: Before and After LSVT BIG

• 71 year-old, diagnosed with Parkinson’s disease in 1994

• Reason for referral: slowness and difficulty walking, history of falls, freezing

• Optimized on PD medications

• Hoehn & Yahr 3

Case Study Outcomes:

Falls 1-2/month 0/month

Assistive device Cane None

Gait Velocity 0.35 m/s 1.17 m/s

% of age matched norm 29.6 % 100%

Endurance 730 ft 1200 ft

PRE POST

To improve his walking

To go to the movies

To play with his grandchildren

To go out to dinner with friends and family

Comparing Exercise in Parkinson’s Disease —The Berlin BIG Study

2010, Movement DisordersGeorg Ebersbach,1* Almut Ebersbach,1 Daniela Edler,1 Olaf Kaufhold,1 Matthias Kusch,1 Andreas Kupsch & Jorg Wissel

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FIG. 2. UPDRS motor score (blinded rating), mean change from baseline (vertical bars 5 standard deviations). Change between baseline and follow up at week 16 was superior in BIG (interrupted line) compared to WALK (dotted line) and HOME (solid line), P <0.001. ANCOVA did not disclose significant differences between in intermediate and final assessments.

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LSVT eLOUD LSVTCompanion

Funded by: NIH‐NIDCD &Michael J. Fox Foundation

Telepractice

LSVT LOUD Technology LSVT Companion OutcomesIncreases in vocal loudness (dB SPL)

Changes consistent with those reported in previously published data Halpern et al., 2012

After treatment, take your daily dose of LSVT LOUD homework exercises!

+ =

The best combination for success!

Lifelong Support After LSVTDaily exercise practice life‐long

• LSVT Homework Helper Video‐Purchase DVD or Download

New Group Exercise Options!• LOUD for LIFE® and BIG for LIFE®

Regular LSVT “Tune‐ups” every 3‐12 months

Other enjoyable activities and fitness for PD

How to get started with LSVT LOUD and LSVT BIG

• Ask your doctor for a referral and a prescription for a speech or physical & occupational therapy evaluationand treatment

• Visit www.lsvtglobal.com to find an LSVT LOUD or LSVT BIG Certified Clinician in your area

Four questions to ask any LSVT LOUD or LSVT BIG therapist

1. Do you deliver the gold standard dosage of LSVT LOUD or LSVT BIG?

• Four days a week for 4 weeks

• Individual 60‐minute sessions

• Daily homework and carryover assignments

2. How many LSVT LOUD/LSVT BIG clients have you treated?

3. What are your typical outcomes?

4. Do you have a follow‐up or maintenance plan for your clients?

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Opportunities to Learn More

• Monthly Webinars on Hot Topics!

• On Demand Webinar Library

• Patients & Family Section

• Featured Blog Articles, Testimonials, and Videos

• Live Seminars

• LSVT Global Facebook Page

• Ask our experts!

FIND IT ALL AT

www.lsvtglobal.com

“If my possessions were

taken from me with one

exception, I would choose

to keep the power of

communication, for by it

I would soon regain

all the rest”

‐Daniel Webster

[email protected]

www.lsvtglobal.com

1‐888‐438‐5788

QUESTIONS??

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Documents

LSVT LOUD Supported by Empowering People Parkinson’s Live